Basic Information
| Provider Information | |||||||||
| NPI: | 1962478636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHALE | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27128 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013874755 | ||||||||
| FaxNumber: | 8014420643 | ||||||||
| Practice Location | |||||||||
| Address1: | 4403 HARRISON BLVD | ||||||||
| Address2: | STE 4835 | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844033271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013874750 | ||||||||
| FaxNumber: | 8013874755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N1138 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208600000X | N1138 | TX | N | Allopathic & Osteopathic Physicians | Surgery | 208D00000X | N1138 | TX | N | Allopathic & Osteopathic Physicians | General Practice | 208200000X | 8501536-1205 | UT | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | U000078865 | 01 | UT | PTAN | OTHER |